This week in Medicare updates—9/4/2019
How to Use the Medicare Coverage Database
On August 26, CMS published an MLN Booklet regarding the Medicare Coverage Database, which provides information on national coverage determinations, local coverage determinations, and several other types of national coverage policy-related documents. The 24-page resource walks users through the search options, indexes, reports, and downloads available through the Medicare Coverage Database.
Comment Request: Hospital Notices: IM/DND
On August 26, CMS published a Comment Request in the Federal Register regarding the submission for OMB review of an information collection titled, “Hospital Notices: IM/DND.” Comments are due to the OMB desk officer by September 25, 2019.
National Background Check Program for Long-Term Care Providers: Assessment of State Programs Concluded in 2017 and 2018
On August 26, the OIG published a Review of whether states implemented background check program requirements after participating in the program in 2017 and 2018. The OIG found that implementation of program requirements varied among the 11 states reviewed. While two states successfully implemented all program requirements, nine of the 11 states failed to implement all the program requirements, primarily because of a lack of legislative authority for certain program requirements. However, five of those nine states implemented most of the program requirements. None of the states showed evidence of unintended consequences associated with conducting background checks (such as a reduction in available workforce, etc.). The OIG, as it has done with similar reviews in the past, strongly encourages CMS to take actions to encourage states to obtain necessary legislative authority to fully implement program requirements.
Updated Civil Monetary Penalties and Affirmative Exclusions
On August 27, the OIG published an updated List of Civil Monetary Penalties and Affirmative Exclusions, including the following:
- On August 13, MDR Diagnostics, LLC, of New Brunswick, NJ, reached a $144,621.98 settlement agreement with the OIG to resolve allegations that it submitted claims for nerve conduction studies that are considered screening exams and are not covered by Medicare.
Comment Request: Medicare Coverage of Items and Services for Coverage with Evidence Development (CED)
On August 27, CMS published a Comment Request in the Federal Register regarding the submission for OMB review of an information collection titled, “Medicare Coverage of Items and Services for Coverage with Evidence Development (CED).” Comments are due to the OMB desk officer by September 26, 2019.
Medicare Part D is Still Paying Millions for Drugs Already Paid for Under the Part A Hospice Benefit
On August 27, the OIG published a Review of whether the Part D program paid for drugs in 2016 that should have been paid for by hospice organizations under the Part A hospice benefit. The OIG found that Part D paid an estimated $160.8 million in 2016 for drugs that should have been paid for by hospice organizations. The OIG states that CMS must do more to avoid paying twice for the same drugs. As it recommended in a previous report on the same topic in 2012, the OIG recommends CMS work directly with hospices to ensure that they are providing drugs covered under the hospice benefit, and CMS should develop a strategy to ensure Part D does not pay for drugs that should be covered by the Part A hospice benefit. Although CMS stated its current efforts will help address the issue, the OIG disagreed that those efforts would adequately address this problem since the duplicate payments persist.
Comment Request: Medicare Outpatient Observation Notice (MOON)
On August 28, CMS published a Comment Request in the Federal Register regarding an information collection titled “Medicare Outpatient Observation Notice (MOON).” Comments are due by October 28, 2019.
Implementation to Send Post-Pay Electronic Medical Documentation Requests (eMDR) to Participating Providers via the Electronic Submission of Medical Documentation (esMD) System
On August 28, CMS published One-Time Notification Transmittal 2355, which rescinds and replaces Transmittal 2325, dated July 24, 2019, to incorporate the correct version of the post-pay data element spreadsheet. The transmittal was previously rescinded and replaced to remove references of the billing provider in the esMD Post Pay Data Elements attachment. The original transmittal was issued regarding implementation of changes to generate and send the ADR Letter Package information to esMD so these letters can be sent electronically as Post-Pay eMDRs.
Effective date: January 1, 2020
Implementation date: October 7, 2019 - Analysis, Design, and Coding; January 6, 2020 - Testing and Implementation
CMS Offers Broad Support for Puerto Rico, Florida with Hurricane Dorian Preparation
On August 28 and 30, CMS published press releases on actions it is taking to support Hurricane Dorian recovery efforts in Puerto Rico and Florida. These actions include temporary waivers for certain Medicare requirements, special enrollment opportunities to allow for immediate access to healthcare, steps to ensure dialysis patients can obtain services, and more.
On August 30, CMS published Special Edition MLN Matters 19017 to provide information on the blanket waivers, extensions, and DMEPOS/prescription replacements granted through Medicare to areas in Puerto Rico affected by the hurricane.
For more information on CMS activities related to tropical storm/hurricane relief, visit CMS’ emergency website.
Mederi Caretenders Home Health Billed for Home Health Services that Did Not Comply with Medicare Billing Requirements
On August 29, the OIG published a Review of whether Mederi Caretenders complied with Medicare requirements for billing home health services. The OIG found that Mederi did not comply with Medicare requirements for 21 of the 71 home health claims paid in CYs 2014 or 2015, causing estimated overpayments of $31,428. These claims were incorrectly billed because the beneficiaries were not homebound, did not require skilled services, claims had incorrect HIPPS codes, or requirements were not adequately documented. The OIG recommends Mederi refund Medicare for the estimated overpayments, exercise reasonable diligence to identify and return any similar overpayments, and strengthen its controls to ensure full compliance with Medicare requirements.
Mederi disagreed with the OIG’s findings and did not concur with any of its recommendations. It stated that the OIG incorrectly interpreted homebound to mean bedridden, did not consider the entirety of the medical record when determining whether a beneficiary required skilled services, erred in determining claims were incorrectly coded, and should not deny payment for quality skilled care if the only discrepancy is a missing face-to-face encounter. The initial OIG report determined 42 of the 71 home health claims were in error, but this number was reduced down to 21 after the OIG reexamined its methodology following some of Mederi’s objections.
Market Saturation and Utilization Data Tool
On August 30, CMS published a Fact Sheet regarding its Market Saturation and Utilization Data Tool. Release 9 of this tool introduces two additional service areas for a total of 19 health service areas. It also includes an additional geographic division of core-based statistical areas. This tool can be used by providers to assist them in making decisions about their service locations and the beneficiary population they serve.
October 2019 Update of the Hospital Outpatient Prospective Payment System (OPPS)
On August 30, CMS published Medicare Claims Processing Transmittal 4387 regarding the October 2019 update of the OPPS. Changes include 34 new proprietary laboratory analyses codes, multiple new CPT Category II codes related to retinal procedures or exams, clarification on guidance for intraocular or periocular injections of anti-inflammatory drugs and antibiotics, and more.
Effective date: October 1, 2019
Implementation date: October 7, 2019
October Quarterly Update for 2019 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Fee Schedule
On August 30, CMS published Medicare Claims Processing Transmittal 4386 regarding the quarterly update to the DMEPOS fee schedule. In addition to the release of the regular data files for download, CMS is also adding fee schedule amounts for HCPCS code E0766 (electrical stimulation device used for cancer treatment, includes all accessories, any type) to the DMEPOS fee schedule file effective September 1, 2019. Suppliers should append modifier -KF when billing this code.
Effective date: September 1, 2019 for implementation of fees for code E0766; October 1, 2019 for all other changes
Implementation date: October 7, 2019
Pub 100-04, Chapter 29 - Appeals Signature Requirement Change
On August 30, CMS published Medicare Claims Processing Transmittal 4380 regarding the implementation of a policy that will remove the regulatory requirement for signatures on all appeal requests. There are also minor technical revisions to Chapter 29 of the manual following implementation of this policy.
Effective date: July 8, 2019
Implementation date: October 1, 2019
Updates to Chapter 1 Payer Only Codes in the Medicare Claims Processing Manual
On August 30, CMS published Medicare Claims Processing Transmittal 4381 regarding changes to some of the Payer Only codes in Chapter 1 of the manual.
Effective date: October 1, 2019
Implementation date: October 1, 2019
Influenza Vaccine Payment Allowances - Annual Update for 2019-2020 Season
On August 30, CMS published Medicare Claims Processing Transmittal 4382 regarding the payment allowances for the 2019-20 version of the flu vaccine and pneumococcal vaccine, which are both based on 95% of the average wholesale price.
On September 3, CMS published MLN Matters 11428 to accompany the transmittal.
Effective date: August 1, 2019
Implementation date: No later than October 1, 2019; for Business Requirement 11428.3.1, November 1, 2019
October 2019 Integrated Outpatient Code Editor (I/OCE) Specifications Version 20.3
On August 30, CMS published Medicare Claims Processing Transmittal 4383 regarding the I/OCE instructions and specifications for the October 1, 2019 update.
On September 3, CMS published MLN Matters 11412 to accompany the transmittal.
Effective date: October 1, 2019
Implementation date: October 7, 2019
2020 Annual Update of HCPCS Codes for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Update
On August 30, CMS published Medicare Claims Processing Transmittal 4385 regarding changes to HCPCS code files and designations that are used to make appropriate payments in accordance with policy for the SNF CB.
On September 3, CMS published MLN Matters 11441 to accompany the transmittal.
Effective date: January 1, 2020
Implementation date: January 6, 2020
Annual Clotting Factor Furnishing Fee Update 2020
On August 30, CMS published Medicare Claims Processing Transmittal 4384 regarding the annual update to the clotting factor furnishing fee, which will be $0.226 per unit when no payment limit for the clotting factor is published either on the ASP or NOC drug pricing files.
On September 3, CMS published MLN Matters 11435 to accompany the transmittal.
Effective date: January 1, 2020
Implementation date: January 6, 2020